Artery Disease Screening Research Articles

Influence of Left Ventricular Diastolic Dysfunction on the Diagnostic Performance of Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve

Our study aimed to demonstrate the influence of left ventricular (LV) diastolic dysfunction on the diagnostic performance of coronary computed tomography angiography-derived fractional flow reserve (CT-FFR). One hundred vessels from 90 patients were retrospectively analyzed. All patients underwent echocardiography, coronary computed tomography angiography (CCTA), CT-FFR, invasive coronary angiography (ICA), and fractional flow reserve (FFR). The study population was divided into normal and dysfunction groups according to the LV diastolic function, and the diagnostic performance in both groups was assessed. There was a good correlation between CT-FFR and FFR (R = 0.768 p < 0.001) on a per-vessel basis. The sensitivity, specificity, and accuracy were 82.3%, 81.8%, and 82%, respectively. The sensitivity, specificity, and accuracy were 84.6%, 88.5%, and 87.2% in the normal group and 81%, 77.5%, and 78.7% in the dysfunction group, respectively. CT-FFR showed no statistically significant difference in the AUC in the normal group vs. the dysfunction group (AUC: 0.920 [95% CI 0.787-0.983] vs. 0.871 [95% CI 0.761-0.943], Z = 0.772 p = 0.440). However, there was still a good correlation between CT-FFR and FFR in the normal group (R = 0.767, p < 0.001) and dysfunction group (R = 0.767 p < 0.001). LV diastolic dysfunction had no effect on the diagnostic accuracy of CT-FFR. CT-FFR has good diagnostic performance in both LV diastolic dysfunction and the normal group and can be used as an effective tool for finding lesion-specific ischemia while screening for arterial disease in patients.

The Audible Handheld Doppler Facilitates Virtual and Blended Care Models During COVID-19

The Wound Bed Preparation (WBP) paradigm was first published in 2000. The paradigm was introduced to highlight the treatment of the “whole patient” and not just “the hole in the patient.” The key messages are to identify/treat the wound cause and examine patient-centered concerns; practitioners should determine if the wound is healable before focusing on the local wound and surrounding region. There is also an emphasis on monitoring the rate of healing, identifying stalled but healable wounds for potential adjunctive therapies, and the need for healthcare systems to facilitate coordinated and integrated interprofessional care. Sufficient blood supply is needed for a wound to heal, and technology can assist in new ways of identifying adequate circulation. Times change, and in this 2021 version of WBP, we have introduced a new way to identify the cause by examining arterial wave forms with a commonly available handheld portable 8-MHz bedside Doppler (audible handheld Doppler [AHHD]) as an alternative to the traditional ankle-brachial pressure index (ABPI). Dr Dieter Meyer has recorded a helpful video outlining the AHHD procedure that can be accessed at https://journals.lww.com/aswcjournal/Pages/videogallery.aspx?videoId=20. There are several advantages of the AHHD versus the traditional ABPI: It is quicker because the patient does not need to be recumbent for 10 to 20 minutes; if needed, the test can be performed with the patient sitting on a chair. There is no squeezing of the calf muscle, which can cause increased pain for the patient. The result is never falsely inflated by calcification of the arteries (ABPI ≥1.3) because the waveform is independent of arterial calcification. Any multiphasic (biphasic or triphasic) wave will result in an AHHD value equivalent to an ABPI >0.9. Comparing AHHD with great toe pressure (>55 mm Hg) is 97.55% specific as an alternative method to rule out arterial disease.1 The screening for arterial disease with only monophasic waveforms triggering an automatic sequential Duplex lower leg Doppler can save healthcare system dollars. The AHHD signal will correctly identify the absence of arterial disease in most persons tested.1 However, there are always exceptions to the rule, including angiosomal (segmental arterial) defects or aberrant arteries. The absence of arterial disease should be confirmed with a physical examination.2 Further, not all patients are mobile or can attend wound care clinics in the community. Given the added risk of novel coronavirus 2019 (COVID-19) infection, and to facilitate virtual and blended care models, the AHHD signal can be recorded by a healthcare professional on a cell phone and transmitted to healthcare facilities with interprofessional wound care experts for leg and foot ulcer care. That is, patient data can be gathered at the bedside by a visiting nurse or qualified healthcare professional with secure connectivity. A comprehensive interprofessional assessment can be completed synchronously or asynchronously. The advantage of a synchronous assessment is that the patient can hear the Doppler sounds and participate in ensuing discussion. The patient can approve management options to adequately address his/her specific concerns. Practitioners can advise patients about realistic outcomes based on their blood supply and ability to manage the wound cause. Although most wounds are healable, practitioners must tailor their approaches to maintenance and nonhealable wounds to emphasize patient-centered concerns.3 With COVID-19 delaying routine patient care and the possibility of viral mutation threatening the continued need for safe interactions, procedures for virtual care and lessons learned from COVID-19 need to be embedded in healthcare systems. Blended care can be combined with WBP principles to optimize wound treatment for improved patient outcomes and lower costs. R. Gary Sibbald, MD, DSc (Hons), MEd, BSc, FRCPC (Med Derm), FAAD, MAPWCA, JM Elizabeth A. Ayello, PhD, MS, BSN, RN, CWON, ETN, MAPWCA, FAAN

Pre-operative ankle-brachial index for cardiovascular risk assessment in simultaneous pancreas\u2013kidney transplant recipients: a simple and elegant strategy!

BackgroundPatients with insulin-dependent diabetes mellitus type 1 (IDDM1) and end-stage kidney disease (ESKD) undergoing simultaneous pancreas kidney transplantation (SPKT) are a population with diffuse atherosclerosis and elevated risk of cardio- and cerebrovascular morbidity and mortality. We aimed to investigate the feasibility of preoperative screening for peripheral arterial disease (PAD), specifically ankle-brachial index (ABI) testing, to predict peri- and postoperative outcomes in SPKT recipients.MethodsMedical data (2000–2016) from all patients with IDDM and ESKD undergoing SPKT at our transplant center were retrospectively analyzed. The correlation between PAD (defined by an abnormal ABI before SPKT and graft failure and mortality rates as primary end points, and the occurrence of acute myocardial infarction, cerebrovascular and peripheral vascular complications as secondary end points were investigated after adjustment for known cardiovascular risk factors.ResultsAmong 101 SPKT recipients in our transplant population who underwent structured physiological arterial studies, 17 patients (17%) were diagnosed with PAD before transplantation. PAD, as defined by a low ABI index, was an independent and significant predictor of death (HR, 2.99 (95% CI 1.00–8.87), p = 0.049) and pancreas graft failure (HR, 4.3 (95% CI 1.24–14.91), p = 0.022). No significant differences were observed for kidney graft failure (HR 1.85 (95% CI 0.76–4.50), p = 0.178). In terms of the secondary outcomes, patients with PAD were more likely to have myocardial infarction, stroke, limb ischemia, gangrene or amputation (HR, 2.90 (95% CI 1.19–7.04), p = 0.019).ConclusionsPre-transplant screening for PAD and cardiovascular risk factors with non-invasive ABI testing may help to reduce perioperative complications in high-risk patients. Future research on long-term outcomes might provide more in depth insights in optimal treatment strategies for PAD among SPKT recipients.

Low-Cost Mobile Device for Screening of Atherosclerosis and Coronary Arterial Disease.

In the context of global health, telemedicine, and low-resource settings, we present a non-invasive smart-phone based device that can be used to screen for atherosclerosis,which is the leading factor for ischemic heart attacks and strokes. Using acustom Android mobile application, our device computes Pulse Wave Velocity(PWV) using the pulse signals from photo-plethysmographic (PPG) probes, which are simultaneously clipped onto the ear, index finger, and big toe of a human subject. Unlike other designs which require the use of an ECG reference, our mobile device uses only PPG signals and is entirely powered by the mobile phone via the USB port. Using the ear signal as a reference, we derived PWV values from two locations: the right index finger, and the right big toe.We present data from a recent clinical study with 78 participants (age 26 to 74) who were divided into three groups: Coronary Arterial Disease ("CAD"), hypertensive group ("PreCAD"), and Healthy controls. The CAD group was clinically diagnosed and confirmed with a CT-scan and calcium scoring. PWV values derived from the finger was found to have too much variance to be clinically useful. However, PWV values derived from the toe location showed significant differences between the groups, even after accounting for age. Measured PWV values were: 10.07 (8.51-12.01) for the older CAD group, 9.39 (7.44-9.75) for the younger CAD group, 8.26 (7.26-9.22) for the older Pre-CAD group, 10.57 m/s (8.5-11.2) for the younger Pre-CAD group, 7.13 m/s (5.97-7.69) for older healthy controls, and 6.71 m/s (4.86-7.26) for the younger healthy control subjects. These results demonstrate good potential value of this mobile PWV device as a simple low-cost screening tool for atherosclerosis and coronary arterial disease.

Potential of photoplethysmogram for the detection of calcification and stenosis in lower limb

Early detection of arterial stiffness (AS) and atherosclerosis in lower limb is useful for the detection of cardiovascular and diabetic foot diseases. We used photoplethysmogram for the screening of peripheral arterial disease (PAD), and detection of AS occurred due to calcification. The study included three different groups (15-normal subjects (group-1), 6-subjects with known calcification (group-2) and 13 PAD patients). Compared to group-1, we obtained a significant increase in rise-time (282.00 vs. 305.50, p value = 0.009) and area under rise-time (AUR) (71.075 vs. 76.085, p value = 0.041) in PAD group. Similarly in group-2 significant decreases in AUR (71.075 vs. 60.825, p value = 0.000), area under diastole (136.347 vs. 110.538, p value = 0.001), Area (209.729 vs. 170.202, p value = 0.000) and 'b/a' (0.697 vs. 0.933, p value = 0.020) ratio was obtained compared to group-1 and significant increase in these features were noted in comparison with PAD group. The present finding may aid in the detection of PAD and AS due to calcification and arrange proper treatments plan.

An interpretation of the Chinese guideline on the diagnosis and management of diabetic foot in 2017

The China International Exchange and Promotion Association for Medical and Healthcare (CPAM), Diabetic foot branch, published the Guideline for the Diagnosis and Management of Diabetic Foot in July 2017, which provides recommendations for the screening of the patients at risk of diabetic foot, diagnosis, treatment, and effective prevention of diabetic foot. In this article, we provided a professional interpretation and comment on the basis of the guideline as follows: ⑴ The prevention of diabetic foot should give priority to early recognition of the at-risk foot, especially early screening and treatment of diabetic peripheral neuropathy and lower extremity arterial disease; ⑵ The treatment of diabetic foot ulcers should take multidisciplinary cooperative therapy, including off-loading, debridement, anti-infective therapy, and improving blood supplement if necessary; ⑶ Ultimately, the goal of treatment is to prevent the cardiovascular and cerebrovascular events, and reduce amputation rate, disability rate and mortality. Key words: Diabetic foot/DI/TH; Guidebooks

Targeted Screening for Peripheral Arterial Disease? Supportive Evidence from the Australian REACH Registry

Targeted Screening for Peripheral Arterial Disease? Supportive Evidence from the Australian REACH Registry

Screening, Evaluation, and Treatment of Peripheral Arterial Disease.

Screening, Evaluation, and Treatment of Peripheral Arterial Disease.

Screening for Peripheral Arterial Disease: An Update

Peripheral arterial disease (PAD) is common disease and associated with significant morbidity and mortality. PAD is caused due to fatty deposition on artery walls that leads to narrowing of the arteries and blockage in the main blood vessels of the lower limb, which may results in discomfort or pain in the legs during walk, as well as poor quality life and an increased risk of death because of heart and cerebrovascular diseases [1-6]. Risk factors for PAD are shown in Figure 1. The main aim of this review is to focus on the status and progress of screening for peripheral arterial disease.

Community-Based Cardiovascular Screening: Detection of Disease in Individuals with No Self-Reported Risk Factors

Introduction: Community-based cardiovascular screening presents an opportunity to detect the presence of cardiovascular disease in individuals who report having no traditional risk factors, and also to identify the presence of those risk factors in those who are unaware of their health status. Identification of both disease and risk factors (e.g. high cholesterol, high blood pressure, diabetes, etc.) creates an opportunity for treatment and management to reduce and prevent cardiovascular events from occurring. Methods: Over 230,000 screening records for individuals who had undergone carotid artery stenosis (CAD), abdominal aortic aneurysm (AAA), or peripheral artery disease (PAD) screening were reviewed. Participants were stratified based on self-reported risk factors as having no risk factors, one risk factor, or two or more risk factors. Self-reported risk factors were also compared with results of screening for blood pressure, blood glucose, and lipid level status. Results: Abnormal findings of CAS, AAA, and PAD were all uncovered in individuals who self-reported as having no traditional risk factors. These abnormal findings included those defined as severe. The review of self-reported risk factors for accuracy demonstrated varying levels of inaccuracies in both under and over-reporting of risk factors. Conclusions: Community-based cardiovascular screening may result in the identification of cardiovascular disease in individuals with no established risk factors. While the underreporting of risk factors has also be demonstrated, it is clear that further research is warranted to better understand the presence of disease in the absence of risk factors.

False positive results of treadmill exercise ECG - we should minimize the unnecessary referrals to invasive coronary angiography

Purpose: False positive (FP) results are common in treadmill exercise ECG testing (TMT) performed for obstructive coronary artery disease (OCAD) screening. It is important to discriminate whether an ischemic response in TMT is a FP result, to avoid unnecessary referrals for invasive coronary angiography (ICA). We determined the clinical factors that were independently associated with a TMT FP result. Methods: We analyzed a cohort of patients referred for ICA for stable coronary artery disease diagnosis, based on clinical judgment and a TMT positive for ischemia, in a single tertiary-care center (2006-2011). Traditional and nontraditional coronary artery disease risk factors, modified Framingham risk score, symptoms, pre-test (TMT) probability of OCAD, left ventricular ejection fraction and ICA results were assessed. OCAD was defined as any luminal narrowing ≥70%, or ≥50% for the left main artery. A FP TMT result was defined as an ischemic response (2006 TMT European Society of Cardiology guidelines) and no OCAD. The predictors of a FP result were determined by the chi-square, exact Fisher and t-student tests when appropriate, and multivariate analysis (logistic regression). The discriminatory power for a FP result, of a model based on those predictive factors, was assessed by the area under the ROC curve (AUC) analysis. Results: 1243 patients were included: 65.2±9.9 years, 63.0% male, mean 10-year Framingham risk 17.8%; 51.1% typical angina and 20.1% atypical angina; 65.4% high pre-test probability of OCAD; 4.3% depressed left ventricular ejection fraction (<55%). Globally, 51.6% of TMT were FP results. The factors independently associated with a FP TMT were: absence of severe angina (OR 22.0, 95% CI 5.3-91.2), presence of atypical angina (OR 17.3, 95% CI 9.4-31.6), absence of angina (OR 3.8, 95% CI 2.9-5.2), female gender (OR 2.4, 95% CI 1.8-3.3), non-smoking (OR 2.1, 95% CI 1.4-3.0), absence of diabetes (OR 1.5, 95% CI 1.1-2.0) and younger age (OR 1.1, 95% CI 1.0-1.1), (all p<0.05). A model considering these factors together had good discriminatory power for predicting a FP result: AUC 0.80, 95% CI 0.78-0.83. Conclusions: Half of positive TMT were FP in a population of patients referred for ICA following clinical judgment and a TMT positive for ischemia. When analyzed together, the absence of angina/severe angina, the presence of atypical angina, female gender, non-smoking, absence of diabetes and younger age have good power for discriminating a FP result. These parameters should be given more relevance in order to avoid some unnecessary referrals for ICA.

Screening for Peripheral Arterial Disease in a Long-term Care Setting

Screening for Peripheral Arterial Disease in a Long-term Care Setting

268 Automated combination of the oscillometric ankle-brachial index and of the Edinburgh questionnaire for the screening and follow-up of Peripheral Arterial Disease

268 Automated combination of the oscillometric ankle-brachial index and of the Edinburgh questionnaire for the screening and follow-up of Peripheral Arterial Disease

ABIおよびbaPWVによる大規模一斉集団血管検診の検討

2010年敬老の日に，参加募集した1,007例を対象にABI，baPWVによるPADの一斉集団検診を実施した。アンケート調査よりPADハイリスク群613例を抽出し，PAD有病率，ABI，baPWVと動脈硬化危険因子との関連を検討した。9例(1.5%)にPAD(ABI≤0.9)を認めた。また，動脈硬化進行例では動脈硬化危険因子を有する例が多かった。

Oscillometric blood pressure measurement: a simple method in screening for peripheral arterial disease

Blood pressure at the ankle level is a reliable indicator of peripheral arterial disease (PAD) and the ankle brachial index (ABI) is a useful non-invasive screening tool for the early detection of atherosclerosis. In the first part of the study, systolic blood pressures obtained by oscillometry and plethysmography were compared in 80 subjects referred for possible vascular disease. In the second part of the study, 31 general practitioners enrolled 1258 consecutive patients aged more than 60 years. ABI was estimated by oscillometry. Patients with an ABI lower than 0.9 were referred to the local hospital for standardized measurements. In the first part, oscillometry showed a sensitivity of 97% and a specificity of 62% with a positive and negative predictive value of 71% and 96%, respectively. In the second part, significant PAD was found in 111 cases corresponding to a prevalence of 12.2%. In this population, the oscillometry showed a positive predictive value of 47%. The presence of PAD was significantly correlated to exercise related leg pain, a diagnosis of hypertension and smoking, whereas no correlation could be found with a diagnosis of heart disease, stroke, or with the presence of diabetes. The prevalence of PAD was sufficiently high in subjects over the age of 60 years to warrant screening. The ankle brachial index based on measurements with an oscillometric device was shown reliable in the exclusion of PAD, thereby fulfilling an important criterion for the use in screening.

Abstract 3118: Different Calculations Of Ankle Brachial Index And Cardiovascular Risk Prediction

The quotient between ankle and brachial blood pressure (ankle brachial index =ABI) is widely used for peripheral arterial disease (PAD) screening. Guidelines on ABI measurement do not uniformly define whether the higher or the lower ankle pressure should be applied to the calculation. We hypothesized that considering the lowest ankle pressure as numerator and the highest brachial pressure as denominator would increase the prognostic impact. Methods: In 831 patients preceding coronary angiography, ABI was calculated for both legs according to the current definition of the American Heart Association (highest ankle pressure/ highest arm pressure) and according to an extended definition (lowest ankle pressure/ highest arm pressure). For each patient the lowest ABI from both legs was used for further evaluation. 15 patients with an ABI &gt;1.5 were excluded. PAD was defined, if an ABI of less than 0.9 could be detected in one leg with each ABI definition. Results: Using the current ABI definition 204 patients (25.0%) and using the extended definition 292 patients (35.8%) with PAD could be identified. Follow-up data (median 6.6 years) was available for 812 patients (99.5%) and 157 patients (19.3%) suffered from cardiovascular events (death, infarction, stroke). Event rate was significantly higher in patients with PAD (current ABI definition: PAD yes / no=28.1% / 16.3%, P&lt;0.0001; extended ABI definition: PAD yes / no=27.4% / 14.8%, P&lt;0.0001). Event rate was 25.0% in 88 patients with an ABI &gt;0.9 using the current and &gt;0.9 using the extended ABI definition. Hazard ratio (95% confidence interval) was 1.5 (1.1–2.1) for patients with PAD using the current ABI definition (P=0.02) and 1.7 (1.2–2.3) for patients with PAD using the extended ABI definition (P=0.004) compared to patients without PAD. In addition, including ABI as continuous variable improved the area under the ROC curve from 0.68 (0.63– 0.73) for a basic model to 0.70 (0.65– 0.75) for a basic model plus ABI based on current definition and 0.71 (0.66 – 0.76) for a basic model plus ABI based on extended definition. Conclusion: Using the highest ankle pressure the real PAD prevalence is underestimated and a group of patients at risk is overlooked. Therefore we recommend the use of the lowest ankle pressure for ABI calculation.

Tu-P9:381 Screening of peripheral arterial disease by means of an oscillotonometric blood pressure monitor

Tu-P9:381 Screening of peripheral arterial disease by means of an oscillotonometric blood pressure monitor

Oscillometric blood pressure measurement: A simple method in screening for peripheral arterial disease

Oscillometric blood pressure measurement: A simple method in screening for peripheral arterial disease

Renal artery stenosis: value of contrast-enhanced ultrasonography

Renal artery stenosis is the most common cause of potentially curable secondary hypertension. For a long time, angiography has been considered the "gold standard" in screening for renal arterial occlusive disease, but it is expensive and invasive. Magnetic resonance angiography and spiral computed tomography are safer alternatives to angiography but are expensive and not widely available. Due to the fact that duplex scanning is noninvasive, it has been advocated since the early 1980s as a screening test for renal vascular disorders. Factors that make duplex ultrasound an attractive screening measure for renovascular disease are its safety, suitability for outpatient use, and low cost. However, the frequency of artery variants, lengthy examination time, and technically inadequate test conditions limit the use of the direct duplex ultrasound detection of renal artery stenosis. Advances in Doppler technology may alleviate some of the current problems related to examination of renal arteries. One such technique is the use of echo-enhancing agents, which increase Doppler signal strength and can improve the sensitivity and specificity in Doppler ultrasound detection of renal artery stenosis.

Screening for peripheral arterial disease in primary care

Screening for peripheral arterial disease in primary care